Analysis Effective Use of Navigation Equipment The navigation team did not make full use of all navigational equipment. The vessel was on a short run, and the master and the mate were familiar with the area, having had extensive experience. However, when the ferry started falling off to starboard rapidly, the bridge team became confused and were unable to remedy the situation. Blind Pilotage Expertise The events of this occurrence took place under blind pilotage conditions. The parallel index technique on a marine radar in relative motion display, stabilized, north-up presentation is used to accomplish a blind pilotage voyage; other navigation equipment was not used to full advantage. The master had not received SEN training and his expertise in using radar and other navigation aids in blind pilotage situations was limited. His proficiency at manoeuvring and navigating the vessel across the river was reliant on using visual cues. When visibility was reduced by fog to less than 30m, the master could not carry out the series of tasks he routinely used to cross the river, as all visual reference was lost. Once clear of the harbour, the vessel quickly fell off to starboard into the easterly flowing river current. The master, being unable to interpret the changing radar display images or information from other navigation equipment, became disoriented. Since no counter rudder and engine manoeuvres were carried out to correct the situation in a safe and timely manner, the ferry veered off its intended course and ran aground. Although the SEN1 training initiates navigators to blind pilotage, it is SEN2 that fully integrates these techniques into work practices. SENL training, on the other hand, does not broach the subject of blind pilotage. SEN training generally is not required for short-run ferry competency certification, although upcoming regulatory changes will see SEN L become compulsory for master, limited certification when vessels are equipped with radars. When issuing continued proficiency endorsements, Transport Canada now assesses the master's basic practical knowledge of and familiarity with the type of radar on board the specific vessel. However, it is unlikely that this practice will effectively address the issue of blind pilotage situations. The new measure would help confirm the individual's ability/familiarity to operate the vessel-specific radar equipment. Groundings attributable to crews using visual navigation techniques in a blind pilotage environment have occurred in the past.3 On the Catherine-Legardeur, the bridge team was essentially trained and experienced in visual navigation, but undertook a blind pilotage voyage. The absence of blind pilotage training precludes the navigation personnel from acquiring these techniques. Acknowledging that severely restricted visibility appears to be a rare occurrence in the Sorel/ Tracy/ Saint-Ignace-de-Loyola region, the masters and mates cannot reasonably be expected to safely execute short-run ferry services under these prevailing conditions. Certification and Safety There is a disparity between the standard terms of the vessel's certificate of inspection and the bridge team's certification of competency. Under such circumstances, limitations as to where or when and under what conditions a ship can operate can be annotated on the certificate of inspection. For example, when a vessel is not equipped with radars, there may be an annotation specifying minimum visibility. Since the Catherine-Legardeur is equipped with gyro-stabilized radars, there is no visibility restriction noted on the certificate of inspection. Although the bridge team may have the requisite certificates of competency for such a vessel, in practical terms, they are without blind pilotage expertise and do not have the competency to safely operate in severely restricted visibility. Consequently, without regulatory restrictions, such as can be noted on the certificate of inspection of the Catherine-Legardeur, the STQ may operate its short-run ferries in severely restricted visibility even though its crews do not have the training to do so. is aware of the operational parameters of its vessels and the certification limitations of the vessels and the officers, is obliged to employ personnel who are appropriately certificated and adequately trained to operate the equipment on board their vessels, and is required to provide directives for guidance of shipboard and shore-based personnel. The owner has recognized the benefits of SEN training. About one-third of the ship's officers have received SEN1 or SENL training and all ship's personnel will have this training by 31March2006. Under these circumstances, the owner should provide clear guidance to the navigation personnel as to the operational parameters of their vessels to ensure that only officers who have received proper radar training and are capable of conducting blind pilotage are permitted to transit in times of restricted visibility. Although not required by regulation, other equipment that could have improved in real-time spatial orientation, such as an electronic chart system, were not fitted on the vessel. Severely restricted visibility in dense fog reduced the bridge team's spatial orientation to a point where they were unable to take appropriate measures to avoid grounding. Without regulatory limitation, the Socit des traversiers du Qubec (STQ) operated its short-run ferry service in any condition of visibility even though the crew could not safely execute this service in severely restricted visibility.Findings as to Causes and Contributing Factors Severely restricted visibility in dense fog reduced the bridge team's spatial orientation to a point where they were unable to take appropriate measures to avoid grounding. Without regulatory limitation, the Socit des traversiers du Qubec (STQ) operated its short-run ferry service in any condition of visibility even though the crew could not safely execute this service in severely restricted visibility. As SEN L training does not address the issue of blind pilotage regime, the safety of short-run ferries operating in restricted visibility will continue to be compromised.Finding as to Risk As SEN L training does not address the issue of blind pilotage regime, the safety of short-run ferries operating in restricted visibility will continue to be compromised. Marine Communications and Traffic Services (MCTS) were advised of the grounding approximately 40minutes after the event.Other Finding Marine Communications and Traffic Services (MCTS) were advised of the grounding approximately 40minutes after the event. Safety Action Taken Socit des traversiers du Qubec Following the occurrence, the company conducted an internal investigation as per its procedures. On 11May, the report was submitted to company managers citing human error. The report contained medium- and long-term recommendations including: that an evaluation of the competency of all navigation officers of the Sorel/ Tracy/ Saint-Ignace-de-Loyola crossing be undertaken and to reassess the qualifications to operate safely the ships of this crossing; that the company formally establish SENL as the minimum radar training for all STQ officers; and that an evaluation be made on the feasability of equipping all fleet vessels with an electronic chart system and an automatic identification system. Over the summer and fall of2004, a detailed evaluation of navigation practices during inclement weather, such as restricted visibility, was undertaken. Company procedures for each short-run ferry were modified according to local operating conditions. For the four short-run ferry services, the following was added to the restricted visibility procedure: master to be assigned radar duty and pay close attention to the intended route; mate to be assigned vessel controls and follow master's instructions; lookout assigned in the wheelhouse during the crossing and, on approaching the wharf, another lookout forward; and blind pilotage practice using the restricted visibility procedure (master using instruments and mate at controls). Blind pilotage practice is to be undertaken by all masters and by all mates who replace masters for at least one crossing during each of their seven-day work periods. All blind pilotage exercises are to be consigned in the vessel's logbook. Safety Concern Transport Canada Transport Canada now conducts informal on-board tests to verify the master's knowledge and familiarity with the type of radar on board a specific vessel before issuing continued proficiency endorsements for master, minor waters certificates. This procedure, instituted in2002 and promulgated through examiner's notices, still leaves a large measure of discretion to local examiners on whether to conduct an oral exam, and/or practical exam, or even to decide if it is necessary for the candidate to take SEN 1 training. Such a procedure leads to an ad hoc assessment of the individual's ability to perform, that may not fully take into account the risks associated with operations in varying conditions and circumstances. In any event, this new procedure does not fully address the deficiency identified in this occurrence-ensuring that the vessel certification of inspection and personnel certification are in harmony. The Board is concerned that the deficiency identified in this occurrence is not fully addressed. Given the action initiated by the owner, the Board will continue to monitor the issue.